Abstract

Previous studies have shown that renal function in type 2 diabetes correlates better with tubular changes than with glomerular
pathology. Since advanced glycation end products (AGEs; AGE-albumin) and in particular carboxymethyllysine (CML) are known
to play a central role in diabetic nephropathy, we studied the activation of nuclear factor κB (NF-κB) in tubular epithelial
cells in vivo and in vitro by AGE-albumin and CML. Urine samples from healthy control subjects (n = 50) and type 2 diabetic patients (n = 100) were collected and tested for excretion of CML and the presence of proximal tubular epithelial cells (pTECs). CML
excretion was significantly higher in diabetic patients than in healthy control subjects (P < 0.0001) and correlated with the degree of albuminuria (r = 0.7, P < 0.0001), while there was no correlation between CML excretion and HbA1c (r = 0.03, P = 0.76). Urine sediments from 20 of 100 patients contained pTECs, evidenced by cytokeratin 18 positivity, while healthy control
subjects (n = 50) showed none (P < 0.0001). Activated NF-κB could be detected in the nuclear region of excreted pTECs in 8 of 20 patients with pTECs in the
urine sediment (40%). Five of eight NF-κBp65 antigen-positive cells stained positive for interleukin-6 (IL-6) antigen (62%),
while only one of the NF-κB-negative cells showed IL-6 positivity. pTECs in the urine sediment correlated positively with
albuminuria (r = 0.57, P < 0.0001) and CML excretion (r = 0.55, P < 0.0001). Immunohistochemistry in diabetic rat kidneys and a human diabetic kidney confirmed strong expression of NF-κB
in tubular cells. To further prove an AGE/CML-induced NF-κB activation in pTECs, NF-κB activation was studied in cultured
human pTECs by electrophoretic mobility shift assays (EMSAs) and Western blot. Stimulation of NF-κB binding activity was dose
dependent and was one-half maximal at 250 nmol/l AGE-albumin or CML and time dependent at a maximum of activation after 4
days. Functional relevance of the observed NF-κB activation was demonstrated in pTECs transfected with a NF-κB-driven luciferase
reporter plasmid and was associated with an increased release of IL-6 into the supernatant. The AGE- and CML-dependent activation
of NF-κBp65 and NF-κB-dependent IL-6 expression could be inhibited using the soluble form of the receptor for AGEs (RAGE)
(soluble RAGE [sRAGE]), RAGE-specific antibody, or the antioxidant thioctic acid. In addition transcriptional activity and
IL-6 release from transfected cells could be inhibited by overexpression of the NF-κB-specific inhibitor κBα. The findings
that excreted pTECs demonstrate activated NF-κB and IL-6 antigen and that AGE-albumin and CML lead to a perpetuated activation
of NF-κB in vitro infer that a perpetuated increase in proinflammtory gene products, such as IL-6, plays a role in damaging
the renal tubule.

There is growing evidence that tubular injury is a major feature in the development of renal dysfunction in type 2 diabetes
(1–9). Tubular cells are are not only affected secondary to glomerular injury but are also primary targets for pathological influences
in diabetes (1–4,8–15). Typical glomerulopathy is present in only one-third of type 2 diabetic patients with microalbuminuria, while another third
demonstrates normal renal structure. The last one-third has no or absent glomerular changes but disproportional severe tubulointerstitial
lesions (2,16–18). In addition, histological studies of chronic renal diseases confirmed that renal function correlates better with tubular
and interstitial changes than with glomerular changes (2,19,20). This indicates that renal pathology in diabetes is only in part explained by glomerulopathy (1–4,20). It has been shown that renal tubular damage can even precede microalbuminuria in the absence of glomerular proteinuria
(11,12,21–24). This favors the hypothesis that pathologic reactions leading to diabetic nephropathy may first occur in the peritubular
microcirculation, where they induce oxidative injury (2,11,12) and subsequent tubular damage.

Tubular cells are direct targets for enhanced glucose levels present in diabetes. Glucose uptake of tubular cells is independent
of insulin, resulting in a direct relation of the plasma glucose concentration to the intracellular glucose level of tubular
cells (7,14,25–27). In addition, excess glucose in the glomerular filtrate leads to enhanced proximal tubular glucose reabsorption, further
augmenting the effects of hyperglycemia on intracellular glucose efflux within the proximal tubule (28,29). On exposure to glucose, tubular cells secrete vasoactive hormones like angiotensin II (due to the activation of the local
intrarenal renin-angiotensin system), transforming growth factor β and matrix proteins (14,30–40). Glucose-dependent metabolic pathways and vasoactive hormones may directly influence tubular and interstitial cells, leading
to renal dysfunction caused by nonglomerular mechanisms (7,9,10,14,30,31). It has recently been demonstrated that high intracellular glucose levels lead to the enhanced formation of advanced glycation
end products (AGEs), in particular carboxymethyllysine (CML)-modified proteins and the subsequent activation of the redox-sensitive
transcription factor NF-κB (41).

AGEs such as CML have the potential to directly target the renal tubular system. The renal tubule, particularly its proximal
segment, is exposed to the glomerular effluent, containing large quantities of AGEs, in particular in diabetes. Furthermore,
in diabetes, tubular cells are exposed to enhanced levels of circulating AGEs by the peritubular capillary network (2,26,39,42–57). The proximal tubule is a site of reabsorption and catabolism of circulating AGEs found in diabetes. AGEs are taken up by
pTECs in the lysosomal apparatus and lead to cellular hypertrophy due to decreased protein breakdown resulting from reduced
lysosomal proteinase activities, with a concomitant stimulation of protein synthesis (43,49). The accumulation of AGEs in renal tubules is reduced by treatment with an inhibitor of advanced glycation, aminoguanidine
(43,57–60). Thus, formation of AGEs might play a central role in the development of tubular dysfunction in diabetic nephropathy (48,57,60–63). AGEs activate intracellular signal transduction systems with the consecutive generation of free oxygen radicals, leading
to activation of the redox-sensitive transcription factor NF-κB and induction of NF-κB-controlled genes such as interleukin-6
(IL-6) (54,56,59,63,64–76). AGEs activate various intracellular second messengers, including mitogen-activated protein kinase (33,34,54,57,59,63,67–77). Furthermore, the nitric oxide synthase activity is inhibited by early glycation end products as well as AGEs in rabbit
tubular epithelial cells in vitro (57,78).

The effects of AGE proteins such as CML are mediated by binding of AGEs to various distinct cellular receptors, which can
be found on different cell types. One of these receptors is the receptor for AGEs (RAGE) (59,63,68–76,79–94). RAGE is a 35-kDa receptor of the IgG superfamily, which is expressed by a variety of cells, including endothelial cells,
tubular epithelial cells, and other cell types (57,59,68–76,79–84,89–97). Increased RAGE expression could be demonstrated in tubular cells in diabetic nephropathy (59,79,95,97).

This raises the question of whether binding of AGEs to RAGE might induce pTEC activation and tubular dysfunction. This study
investigates the hypothesis that in diabetes, AGE-albumin and/or CML-modified albumin interact with tubular cells in a RAGE-dependent
manner, thus inducing oxidative stress and subsequent activation of NF-κB and NF-κB-controlled genes. This may lead to damage
of the renal tubulus system and appearance of NF-κB and IL-6-positive pTECs in the urine of diabetic patients.

Animal experiments.

Kidneys obtained from diabetic BB/O(ttawa)K(arlsburg) rats were used as diabetes model. This animal model is described in
detail by Klöting et al. (98). Diabetes was present for 57 ± 9 days at an age of 104 ± 16 days. Rats were treated with a continuous infusion of insulin
at 2 units/24 h, and the blood glucose level was kept at >20 mmol/l. Kidneys from normal Sprague-Dawley rats served as a control.
Paraffin-embedded kryostat sections from rat kidneys were prepared from normal and diabetic animals according to a standard
protocol.

Immunohistochemistry.

Immunohistochemistry was performed on paraffin-embedded tissues of a human kidney (obtained from kidney biopsy) and rat kidneys
by indirect immunoperoxidase technique. Detection of signals was performed with the Vectastain ABC kit (Vector Laboratories)
according to the manufacturer’s instructions as described (68–70,75,99–101). Peroxidase activity was visualized with 0.05% 3,3-diaminobenzidine-tetrahydrochloride (Serva, Heidelberg, Germany) before
the sections were counterstained with Mayer’s hematoxylin. Controls for immunstaining were included in all stainings by omission
of the primary antibody and its replacement by PBS and matching concentrations of normal rabbit serum (data not shown). In
addition, blocking peptides were included in some of the reactions to confirm specificity (data not shown).

Patients.

For the investigations, each patient gave informed consent and the study was approved by the ethical committee of the Department
of Medicine, University of Heidelberg, and performed in accordance with the Declaration of Helsinki.

Urine samples from healthy control subjects (n = 50) and type 2 diabetic patients (n = 100) were collected from morning spot urine and immediately stored at −20°C. Information about the clinical and laboratory
data from the patients is given in Table 1.

Quantification of CML formation by enzyme-linked immunosorbent assay.

Quantification of urinary CML was performed using a commercially available kit as previously described (102).

Immunocytochemistry.

Immunocytochemistry staining was performed as described in detail elsewhere (70,79,87). In brief, fresh urine samples were obtained from healthy control subjects (n = 50) and type 2 diabetic patients (n = 100). After direct centrifugation, the supernatant was decanted and the concentrated cellular material was deposited on
glass slides by cytocentrifugation (Shandon Cytospin). Tubular epithelial cells were identified on May-Grünwald/Giemsa (Pappenheim)
staining and by positive reactions with antibodies against cytokeratin 18 and neutral endopeptidase. In a second step, cells
were stained with a monoclonal mouse antibody against NF-κBp65 antigen (Roche) and a FITC-labeled monoclonal mouse antibody
against IL-6 antigen using a standard protocol. The NF-κB antibody recognizes activated NF-κBp65 (103). Staining was performed using anti-NF-κBp65 and anti-IL-6 at a concentration of 0.01 μg/ml for 60 min at room temperature.

Cell culture.

Human renal pTECs were obtained from adult kidneys after surgery from the unaffected parts of kidneys obtained from tumornephrectomy
or kidney biopsies, as described (104–106). Proximal tubular epithelial cells (pTECs) were characterized by staining with FITC-labeled cytokeratin 18 antibodies and
an antibody against neutral endpeptidase as described in immunocytochemistry. For electrophoretic mobility shift assay (EMSA)
analysis, Western blot, and enzyme-linked immunosorbent assay (ELISA), pTECs from the same passage were used (fourth to fifth
passage). Before stimulating pTECs with AGE-albumin or CML, cells were cultivated without growth factors for 5 days. Where
indicated, cells were preincubated with sRAGE (a soluble and truncated form of the receptor RAGE) (70,71,75,83,92,93,96) in a threefold molar excess (1.5 μmol/l) compared with AGE-albumin or CML, a RAGE-specific antibody (20 ng/μl), or TA (200
μmol/l).

Preparation and characterization of AGE-albumin and CML.

AGE-albumin was prepared as previously described (70,96,107). The extent of lysine modifications in the AGE preparations varied up to 36%. In vitro synthesis of CML-albumin was performed
as previously described by Schleicher and colleagues (52,96). Assays for endotoxin showed AGE-albumin and CML preparations to contain virtually undetectable levels of lipopolysaccharide
(LPS) (<10 pg/ml at a protein concentration of 5 mg/ml according to the Limulus assay [Sigma]).

EMSAs.

After stimulation of pTECs with AGE-albumin and CML with the concentrations and time points indicated in the figure legends
(Figs. 3, 4, and 6), nuclear proteins from pTECs were harvested as described elsewhere (67,70,96,99,100) and assayed for transcription factor binding activity using the NF-κBp65 consensus sequence: 5′-AGTTGAGGGGACTTTCCCAGGC-3′. Specificity of binding was ascertained by competition with a 160-fold molar excess of unlabeled consensus oligonucleotides
and supershift experiments. For supershift experiments, nuclear extracts were preincubated with antibodies against NF-κBp65,
-p50, -p52, -cRel, and -relB prior to stimulation as described elsewhere (50,51,56,67,69,70,96,99,100,108–111). All experiments were performed at least three times.

Immunoblot (Western blot) analysis.

Cytoplasmic and nuclear fractions were prepared as previously described in detail (69,70,99,100). Western blot was performed as described. Membranes were incubated with primary antibodies directed against NF-κB65 and
-κβα. After washing, the secondary antibody (horse radish peroxidase-coupled rabbit IgG) was added and incubation was continued
for 30 min. Immunoreactive proteins were detected with the ECL-Western blot System (Amersham Pharmacia, Braunschweig, Germany)
and subsequent autoradiography for 2 min. All experiments were performed three times.

Plasmids.

The simian virus 40–driven luciferase control plasmid pGL2-control, the promoterless plasmid “pGL2-basic,” and the β-galactosidase
control plasmid “pSV-Gal” were obtained from Promega (Heidelberg, Germany). The plasmid NF-κB-Luc, which contains four tandem
copies of the NF-κB consensus sequence fused to a TATA-like promoter region from the Herpes simplex virus thymidine kinase
promoter, was purchased from Clontech (Heidelberg, Germany). The Iκβα expression plasmid was kindly provided by Dr. Baeuerle
(Tularic Inc.).

Transient transfection experiments.

For transfection experiments, pTECs growing in the logarithmic phase were transfected as described (67,70,93,96,99,100,112) using Fugen 6 transfection reagent (Roche) according to the manufacturer’s instructions. Before cells were stimulated with
AGE-albumin or CML (concentrations and time points are indicated in the figure legends), medium was changed and cells were
kept without growth factors and FCS. Cotransfection was performed as previously described (69,70,96,100) with a κBα-overexpressing plasmid. After 42 h, cells were washed with 37°C warm NaCl 0.9% for two times and harvested as
described elsewhere (69,70,96). For inhibition experiments, TA (200 μmol/l), sRAGE (1,500 nmol/l), or anti-RAGE (20 ng/μl) was combined with AGE-albumin
or CML (500 nmol/l). The ratio of luciferase activity to β-galactosidase activity served to normalize luciferase activity
(112). Each experiment was performed in triplicates, and experiments were repeated at least three times.

Determination of IL-6 antigen.

The supernatant from NF-κBp65 or inhibitory κB (IκB)α-transfected and AGE- or CML-stimulated cells was harvested and IL-6
antigen determined by ELISA. The ELISA for determination of IL-6 was performed using a commercially available kit (Promocell)
according to the instructions of the manufacturer. The experiment was performed in triplicates and repeated at least three
times.

RESULTS

NF-κB activation in the kidney.

Paraffin-embedded tissues from diabetic BB/O(ttawa)K(arlsburg) (98) rat kidneys were prepared to demonstrate NF-κBp65 and -p50 antigen. Diabetes was present for 57 ± 9 days and manifested
at an age of 104 ± 16 days. Normal Sprague-Dawley rats served as a control group. In diabetic animals, NF-κBp50 and -p65 antigen
was present in the nuclear region of tubular cells (Fig. 1B and D), while in control animals, no NF-κBp50 and -p65 antigen could be detected in tubular cells (Fig. 1A and C). Interestingly, in diabetic kidneys, NF-κBp50 and -p65 was mainly present in tubular cells and not in glomerular cells.
To confirm these data, kidney specimens derived from a kidney biopsy of a patient with diabetic nephropathy were stained with
the same antibodies. Tubular epithelial cells showed a marked staining for NF-κBp65 and -p50 antigen (Fig. 1E and F). Again, NF-κBp65 and -p50 were mainly present in the renal tubular system.

Excretion and activation of tubular epithelial cells in diabetic patients.

Urine was collected from 50 healthy control subjects and 100 patients with type 2 diabetes (50 patients with normal albumin
excretion [<20 mg/l] and 50 with macroalbuminuria [>200 mg/l]). Mean serum creatinine and urea had been normal. In addition,
urine from 50 nondiabetic patients with macroalbuminuria [>200 mg/l] was collected. Patient characteristics are shown in Table 1. Urinary excretion of CML-modified proteins was determined by ELISA. Diabetic patients showed significantly higher urinary
CML levels than healthy control subjects (P < 0.0001) or nondiabetic patients with macroalbuminuria >200 mg/l (P < 0.0001). These results are in contrast to a recently published study that showed a decreased urinary excretion of CML in
diabetic patients with impaired renal function (102). This is most probably due to an increase in CML excretion, while renal function is not severely impaired. With decreasing
renal function, CML can be excreted only to a lesser extent. When the diabetic patients were further analyzed, a positive
correlation between albuminuria and excretion of CML antigen (r = 0.7, P < 0.0001) was found, while there was no correlation between CML excretion and HbA1c (r = 0.03, P = 0.76).

The presence of pTECs in the urine was evidenced using antibodies against cytokeratin 18 and neutral endopeptidase. Single
or scattered pTECs (Fig. 2A and B) were found in the urine of 20 of 100 type 2 diabetic patients but in none of the healthy control subjects (P < 0.0001). Positive staining for activated NF-κBp65 antigen was recognized in 8 of 20 (40%) patients, in some but not all
excreted pTECs (Fig. 2C). Furthermore, to indirectly assess the transcriptional consequences of NF-κBp65 activation, slides were incubated with an
antibody against IL-6. In five of eight patients positive for NF-kBp65, IL-6 antigen could be detected (62%) in single cells
(Fig. 2D), whereas in the preparations negative for NF-κBp65, only one expressed the IL-6 antigen (1/12).

NF-κB activation in cultured pTECs.

In vitro experiments were performed using cultivated human pTECs to prove that tubular cells indeed have the ability to activate
NF-κB in response to increased AGEs. pTECs were stimulated with either AGE-albumin or CML as described in research design and methods. When cultured pTECs were incubated over 6 h with either AGE-albumin (Fig. 3A) or CML (Fig. 3B), a dose-dependent activation of NF-κB was observed in EMSA (Fig. 3A and B). NF-κB binding activity was half maximal at 250 nmol/l AGE-albumin and 500 nmol/l CML. Normal nonglycated human albumin
did not induce NF-κBp65 (Fig. 3E). Heat inactivation of AGE-albumin over 12 h at 100°C abolished inducible NF-κB binding activity (data not shown).

AGE-albumin and CML induced NF-κB binding activity in a time-dependent manner (Fig. 3C and D). An early start of NF-κB activation was observed already at 30 min, reaching a first maximum after 6 h (Fig. 3C, lane 4). After a decrease between 12 and 24 h (Fig. 3C, lanes 5 and 6), a second peak could be observed after 4 days (Fig. 3C, lane 7). This time course is similar to the data obtained in a previous study (70). Stimulation of pTECs with CML revealed similar data compared with stimulation with AGE-albumin (Fig. 3D).

Supershift analysis (Fig. 4) revealed that NF-κBp65 and -p50 (lanes 4 and 6) constituted the major protein contributing to the shift observed, while NF-κBp52, -cRel, and -RelB did not participate in
the binding reaction. NF-κB binding activity was suppressed using a sixfold excess of unlabeled oligonucleotides (lane 9). Heat-inactivated AGE did not activate NF-κB in cultured pTECs (lane 1).

Western blot analysis corresponded well to the binding activity demonstrated in EMSA analysis. After AGE-albumin or CML stimulation,
NF-κBp65 antigen translocation was dose dependent (Fig. 5A and B). The decrease in cytoplasmic p65 antigen occurred after 60 min, simultaneously with the increase in nuclear p65 antigen
(Fig. 5C and D). Correspondingly, IκBα degradation was also dose and time dependent (Fig. 5A–D). A reconstitution of cytoplasmic NF-κBp65 antigen was observed at 3–4 days (lanes 8 and 9), a time point of maximal NF-κBp65 binding activity (Fig. 3) and nuclear translocation (Fig. 5C and D). A previous report demonstrated that long-lasting NF-κBp65 activation is associated with increased NF-kB synthesis, overriding
IκBα, explaining simultaneous nuclear and cytoplasmic NF-κBp65 antigen (70). Consistently, a strong loss of κβ α antigen was observed after a 12-h stimulation, but not after 4 days (Fig. 5C and D), presumably because NF-κBp65 drives the de novo synthesis of IκBα (70).

As shown by EMSA (Fig. 3), NF-κBp65 activation started after 30 min, reaching a first maximum after 6 h and a second maximum at 4 days after CML stimulation
and thus resembled the activation pattern observed for AGE-albumin. In Western blot analysis, however, translocation of NF-κBp65
from the cytoplasm into the nucleus was already observed 30 min after AGE stimulation, but not 6 h after CML stimulation,
which might be due to a lesser stimulatory effect of CML compared with AGE-albumin. Since EMSAs are much more sensitive than
Western blots, it is reasonable to assume that a weaker CML-dependent NF-κB induction can be monitored in EMSA but is not
evident in Western blot analysis.

All effects could be reduced using the antioxidant TA. The reduction could be observed in EMSA analysis and Western blot (Fig. 6A and B and Fig. 7A). To investigate whether the AGE-albumin- and CML-induced NF-κBp65 activation is RAGE dependent, coincubation with sRAGE
and a specific RAGE-antibody was performed. sRAGE and RAGE antibody decreased NF-κBp65 activation in EMSA (Fig. 6C and D) and Western blot (Fig. 7B).

Transcriptional activity of NF-κB.

Transient transfection of cultured pTECs, using a NF-κB consensus-driven luciferase reporter plasmid, was performed to demonstrate
that increased NF-κB binding activity (Fig. 3) and nuclear translocation (Fig. 5) is functionally significant and results in increased NF-κB-dependent gene expression. A dose-dependent activation could
be demonstrated when pTECs were stimulated with AGE-albumin or CML (Fig. 8A and B), corresponding well to the data concerning NF-κB activation in EMSA analysis (Fig. 3) and Western blot (Fig. 5). When cells were stimulated for 6 h with 500 nmol/l AGE-albumin or CML, respectively, an 8- (CML) to 10-fold increase (AGE)
in luciferase activity was observed (Fig. 8A–D). This was not the case when cells were stimulated with control albumin. Overexpression of κβ and treatment with the antioxidant
TA reduced luciferase activity (Fig. 8C and D). Furthermore, NF-κB activation is RAGE dependent, since AGE-albumin-induced binding activity was markedly inhibited by addition
of excess sRAGE and RAGE antibody, as described in research design and methods (Fig. 8C and D). Due to experimental limitations of transient transfection experiments, the time of stimulation could not be exceeded for
>42 h.

AGE-albumin- and CML-mediated pTEC activation resulted not only in increased expression of luciferase but also in de novo
synthesis of IL-6 antigen (studied as a model of a NF-κB-driven gene). When the supernatants of the transfected cells (transfection
data are shown in Fig. 8) were analyzed for IL-6 antigen, a dose-dependent increase was observed (Fig. 9A and B). IL-6 antigen release was reduced by overexpression of IκB or addition of the antioxidant TA. Furthermore, the IL-6 antigen
induction is RAGE dependent, since sRAGE and RAGE antibody reduced IL-6 release (Fig. 9C and D).

DISCUSSION

Human pTECs are not only passive bystanders in the development of diabetic nephropathy, but they also respond actively to
hyperglycemia and AGEs by inducing NF-κB activation and NF-κB-dependent gene expression in vitro and in vivo. One defined
AGE generated by lipoxidation and glycoxidation in diabetic nephropathy is CML (44,52,61,70,114). The presence of CML-modified proteins in the urine of type 2 diabetic patients and the in vitro observation that CML is
a potent inducer of sustained NF-κB activation in pTECs suggest that CML might play a role in the development of diabetes
renal complications. In addition, the observation that type 2 diabetic patients demonstrated excretion of tubular cells that
was positive for activated NF-κBp65 and IL-6 antigen implies that the AGE/CML-RAGE-mediated NF-κB activation is functionally
significant.

Indirect evidence for the role of NF-κB activation in diabetic nephropathy has already been given from clinical studies in
which an increase in oxidative stress correlated with renal function and NF-κB activation in patients with type 2 diabetes
(99,100,115–118). We found that increased CML excretion in type 2 diabetes correlates to the excretion of NF-κBp65 and IL-6 antigen-positive
pTECs.

As demonstrated here, pTECs respond to exogenously added AGE-albumin and CML with an NF-κB activation that meets the requirements
of RAGE-dependent NF-κB activation, as evidenced by NF-κB binding activity that lasted >4 days and NF-κB-dependent gene expression
(69,70). In vivo, pTECs are exposed not only to AGEs present in the urine but also to glucose leading directly to intracellular
AGE formation (41). An additional source of intracellular CML formation is the inflammatory reaction, as we have shown that pTECs in diabetic
patients are in part positive for IL-6. Cytokines and inflammatory agents, as they occur in time remodeling, are associated
with intracellular CML formation and activation of NF-κBp65. It remains unknown whether pTECs are subject to extracellular-
and/or intracellular-mediated CML responses in diabetes. Until now, only cell responses to extracellular AGEs, for example
via RAGE, have been reported. The involvement of RAGE in AGE-dependent pTEC activation was confirmed by competition of NF-κB
activation by sRAGE and an RAGE blocking antibody. This in agreement with recent data showing reduction of vascular hyperpermeability
by scavenging RAGE ligands (75,91,92,119,120) and increased diabetic nephropathy in diabetic animals overexpressing RAGE (93). Furthermore, there is evidence that RAGE-ligand interaction contributes to sustained NF-κBp65 activation (41,68–70,83,121,122). The long-lasting nature of RAGE-dependent NF-κBp65 activation corresponds well to the p65 and p50 positivity of tubular
cells in the tissue sections shown in Fig. 1. One would not expect all cells to be positive, even in serial sections, if NF-κB activation in humans would be as short
lasting as in tissue culture after tumor necrosis factor stimulation. Thus, in diabetes, autoregulatory negative feedback
loops are shut down. As shown previously, one mechanism is excessive de novo synthesis of p65, overriding IκBα inhibition
(70,123–125). Since many stimuli result in NF-κB activation, one has to assume that mechanisms for cell- and disease-specific activation
must exist.

It has been demonstrated that different stimuli in different renal diseases lead to disease-specific activation of certain
NF-κB subunits. Using LPS as stimulus, or other renal models like rats with ureteric obstruction or immune complex nephritis,
different activation patterns could be observed (50,51,55,56,108–111,126). This suggests that differences in the NF-κB activation pattern in response to a given stimulus might determine the selection
of the genes activated. Therefore, we investigated which activation pattern is present in human pTECs due to AGE-albumin stimulation.
We and others show two specific DNA-protein complexes (50,51,56,111). Supershift analysis revealed that the slower-migrating complex is composed of NF-κBp65 and -p50. In accordance with other
studies, the faster-migrating band could not be depleted could by NF-κBp65, -p50, -p52, -cREL, or -relB antibodies but could
by unlabeled oligonucleotide. To define whether the complex is due to the binding of a coactivator protein such as CBP/p300
(111), however, is beyond the scope of this study.

The observation that excreted pTECs demonstrate both NF-κB and IL-6 antigen activation led us to speculate that a perpetuated
increase in proinflammtory gene products such as IL-6, depending on perpetuated NF-κB activation (as demonstrated in vitro),
might be central in damaging the renal tubule. This view is emphasized by the fact that not only cytokines, but also metalloproteinases
such as MMP9, are controlled by NF-κB. MMP-9 has been implicated to contribute to proteinuria in Heymann nephritis and therefore
might be a good candidate for the destruction of pTECs in the course of diabetic nephropathy (127).

Further studies are needed to define which mechanisms are activated by perpetuated NF-κB activation and finally result in
the destruction of the tubulus, as evidenced by the excretion of pTECs in overt diabetic nephropathy.

NF-κB in rat and human kidney. Paraffin-embedded tissue specimens of rat kidneys and a human diabetic kidney were stained
with a polyclonal antibody against NF-κBp50 and -p65 antigen (indicated as brown color). Control animals showed no NF-κBp50
(A) and no NF-κBp65 antigen (C), while in diabetic rats, NF-κBp50 (B) and NF-κBp65 antigen (D) were detectable in tubular cells and mainly present in the perinuclear region. Human diabetic kidney expressed NF-κBp50
(E) and NF-κBp65 antigen (F).

NF-κBp65 and IL-6 antigen in urinary excreted tubular epithelial cells. A and B: Cells were obtained from the urine of a type 2 diabetic patient. Detection of pTECs was performed using cytokeratin 18 antigen
(A) and neutral endopeptidase (B) as markers. The figures show a marked positivity in scattered cells for cytokeratin 18 antigen (A) or neutral endopeptidase (B). C: Detection of NF-κBp65 antigen in pTECs using an antibody recognizing activated NF-Bp65. D: Single cells were stained with an antibody recognizing IL-6-antigen. A–D: Magnification 550×.

NF-κB binding activity in pTECs in vitro: EMSA. pTECs were either left untreated (Cont) or stimulated with AGE-albumin or
CML as described in research design and methods. Nuclear extracts were prepared (see research design and methods) and studied for the presence of NF-κBp65. The position of NF-κB is indicated by an arrow (65 kDa). The results shown are
representative of at least three independent experiments. One representative experiment is shown. Dose response: cells were
incubated for 6 h with the indicated concentrations of AGE-albumin (A) or CML (B). Time course: cells were incubated for the indicated periods with 500 nmol/l AGE-albumin (C) or CML (D). Nonglycated human albumin did not induce NF-κBp65 (E).

Characterization of NF-κB binding activity by “supershift” analysis. To further characterize the NF-κB subunits, contributing
to the observed “shift,” cells were stimulated with 500 nmol/l AGE-albumin for 3 h, nuclear extracts were prepared, and 2.5
μg of antibodies against NF-κBp50, -p52, -p65, -cRel, or -RelB antigen were included in binding reaction. The position of
NF-κB and the “supershift” is indicated by arrows. α, antibody; Cons, 160-fold excess of unlabelled consensus oligonucleotide;
Control, unstimulated pTECs; H, heat-inactivated AGE-albumin.

AGE- and CML-dependent NF-κB activation in vitro: Western blot. pTECs were stimulated with AGE-albumin and CML, and cytoplasmic
and nuclear extracts were obtained as described in research design and methods. For analysis, a monoclonal antibody against NF-κBp65 and IκBα antigen was used. The results shown are representative of
at least three independent experiments. One representative experiment is shown. The localization of NF-κBp65 antigen in the
nucleus and cytoplasm (Cytopl.) and IκB in the cytoplasm is indicated by arrows. Dose dependence: stimulation for 6 h with
various concentrations of AGE-albumin (A) or CML (B). Time dependence: stimulation with 500 nmol/l AGE-albumin (C) or CML (D) over a period of 30 min to 5 days. Cont, unstimulated cells.

Inhibition of NF-κBp65 binding activity TA and inhibition of ligand-RAGE interaction: EMSA analysis. pTECs were either left
untreated or stimulated for 6 h with 500 nmol/l AGE-albumin (AGE) (A and C) or CML (B and D) in the presence of 200 μmol/l TA (A and B), sRAGE (1,500 nmol/l), or RAGE antibody (20 ng/μl) (C and D). The data shown are representative of at least three independent experiments. One representative experiment is shown. The
position of NF-κBp65 is indicated by arrows. NF-κBp65 activation induced by AGE-albumin (A and C, lane 2) or CML (B and D, lane 2) is inhibited by TA (A and B, lane 3), sRAGE (C and D, lane 3), or RAGE-specific antibody (C and D, lane 4).

Inhibition of NF-κBp65 nuclear translocation by TA and inhibition of ligand-RAGE interaction. Western blot. Before stimulation
over 6 h with 500 nmol/l AGE-albumin, pTECs were incubated with TA (200 μmol/l), sRAGE (1,500 nmol/l), or RAGE-antibody (20
ng/μl). After 6 h, nuclear and cytoplasmic extracts were obtained for immunoblot as described in research design and methods. The data shown are representative of at least three independent experiments. The position of NF-κBp65 and IκBα is indicated
by arrows. NF-κB activation by AGE-albumin (A and B, lane 2) could be inhibited by TA (A, lane 3), sRAGE (B, lane 3), or RAGE antibody (B, lane 4).

Transcriptional activity of NF-κBp65. pTECs were transiently transfected with the reporter plasmid NF-κB-Luc (see research design and methods). After transfection, cells were left unstimulated, stimulated with control albumin, or stimulated with various concentrations
of AGE-albumin (A) or CML (B) for 6 h. Where indicated, cells were cotransfected with a κBα-overexpressing plasmid (C and D, lane 4) or treated with 200 μmol/l TA (C and D, lane 5), 1,500 nmol/l sRAGE (C and D, lane 6), or 20 ng/μl RAGE antibody (C and D, lane 7). After harvest, luciferase activity was determined in the cell lysates. Values are expressed as relative luc units. Three
independent experiments were performed with identical results. One representative experiment is shown.

Transactivation capacity of NF-κB. Determination of IL-6 antigen in the cell supernatant after stimulation of transfected
pTECs for 6 h with various concentrations of AGE-albumin (A) or CML (B). AGE-albumin-induced (C, lane 3) or CML-induced increase (D, lane 3) in IL-6 antigen could be reversed by overexpression of IκBα (C and D, lane 4), TA (C and D, lane 5), sRAGE (C and D, lane 6), and anti-RAGE (C and D, lane 7). Three independent experiments were performed with identical results. One representative experiment is shown.

Acknowledgments

This work was supported by grants from the University of Heidelberg (to M.M. and A.B.) and the University of Tübingen (to
A.B. and P.P.N.), the IZKF program of the University of Tübingen (to P.P.N.), and Asta Medica (to A.B. and P.P.N.). P.P.N.
performed part of this work during the tenure of a Schilling professorship. A.B., B.Y., E.S., H.U.H., F.v.W., and P.P.N. were
supported by the Deutsche Forschungsgemeinschaft. A.-M.S. and D.S. were supported by grants from the USPHS, the American Heart
Association (New York affiliate), and the Juvenile Diabetes Foundation. A.A.R.S. is supported by a grant from the Arab Republic
of Egypt.

We thank Dr. M.A. Shearman (Merck, Sharpe & Dome) for providing anti-RAGE antibodies, Dr. Baeuerle (Tularic Inc.) for providing
Iκβα expression plasmid, and Dr. Kientsch-Engels (Roche AG) for providing the CML-ELISA kit. Part of this report was presented
at the meeting of the German Diabetes Society 2001 (Aachen, Germany).